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General NPI Number Information
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NPI Number | 1114689585
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Entity Type | Organization
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Legal Business Name | AGING GRACEFUL CARE LLC
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Dates
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Enumeration Date | 10/12/2021
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Last Update Date | 01/06/2024
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Provider Practice Location Address
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Address Line | 5160 HICKORY POINT FRONTAGE RD
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City | DECATUR
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State | IL
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Zip | 62526-9778
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Country | US
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Telephone | 217-247-3120
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Fax |
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Provider Business Mailing Address
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Address Line | 2610 S FORREST GREEN DR
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City | DECATUR
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State | IL
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Zip | 62521-5411
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Country | US
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Telephone | 217-454-9645
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Fax |
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | MRS. TOSHA COBB
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Credential | PTA,LMT
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Telephone | 217-454-9645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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